Wednesday, November 25, 2009

Peristomal Skin Complications and Management -- an Article Review

There is a very nice review article in the “throw away” journal Advances in Skin & Wound Care (full reference below) which discusses the causes and management of peristomal skin complications.  The photo (credit) to the right shows normal, healthy skin around a stoma.

Peristomal complications are one of the most challenging aspects of living with ostomies.  The purpose of this review article was stated to be “to illustrate practical approaches to prevent and treat common peristomal skin conditions.”

The authors propose the use of the mnemonic MINDS to help clinicians remember and be mindful of the potential
causes of peristomal skin problems:

M:  Mechanical trauma from the ostomy equipment and skin stripping
I:     Infection (bacterial and fungal)
N:  Noxious chemical and irritants including strong alkaline, feces, or urine
D:   Diseases of the skin that are common in persons with ostomies, such as pyoderma gangrenosum, psoriasis, and so on
S:    Skin allergens

The article then proceeds to address each of those with suggestions for each.

There is a nice table of sealants/protectants which can be used to minimize skin stripping (mechanical) due to loss of epithelial cells with repeated application and removal of adhesive tapes and appliances.  The photo (credit) to the right show a severe case of contact dermatitis surrounding a stoma.

Silicones are polymers that include silicone together with carbon, hydrogen, oxygen.  These are applied to the peristomal skin.
Zinc oxide powder is an inorganic compound that is insoluble in water.  It is applied generously to skin.  It ma interfere with activity of ionic silver.
Acrylates form a protective interface on skin attachment sites.  They are sprayed or wiped on skin sparingly.  Allergy is uncommon.
Hydrocolloid wafers consists of a backing with carboxymethylcellulose as the filler, water-absorptive components, such as gelatin and pectin (commercial gelatin desserts), and an adhesive.  Window frame the stoma to prevent recurrent stripping of skin.  Allergies have been reported from some colophony-related adhesives that are associated with some hydrocolloid dressings

The article addresses another mechanical issue, urostomy encrustations, which affect about 20% of people with a urostomy.  These encrustations are precipitation or crystals of phosphates and uric acid caused by accumulation (stagnation) of urine, alkaline urine, and infection.

These reddish-brown and gritty deposits produce a localized inflammatory change that resembles the wart virus clinically and is referred to as false wartlike lesions (pseudoverrucous lesions [Figure 2]) or
pseudoepitheliomatous hyperplasia.

Other signs and symptoms may include localized pain, erythema, or a loss of the superficial epidermis, with the remaining epidermis forming the base (erosion).

This condition is mainly caused by improper skin barrier/pouch with an opening that is too large for the stoma, leading to urine leakage around the peristomal
skin.

Treatment is directed at the specific problem as outlined in Table 3. Other strategies may entail the use of a urostomy pouch that has a 1-way valve to prevent retrograde flow of urine, a convex pouching system for uneven peristomal skin or recessed stomas, and proper sizing of skin barrier and pouch, so peristomal skin is not chronically overexposed to effluent.

If you take care of patients with osteomies, then check out the article for their discussion of the other causes.  An osteomy expert may not find it informative, but for the rest of us its is.  The article includes some nice photos which illustrate the different problems.

For all you general surgery residents, check out this  video of a preoperative stoma marking done by Sterile Eye.  Proper placement of a stoma can alleviate a lot of problems.

 

REFERENCE

Peristomal Skin Complications and Management; Advances in Skin & Wound Care. 22(11):522-532, November 2009 [doi: 10.1097/01.ASW.0000305497.15768.cb]; Woo, Kevin Y.; Sibbald, R. Gary; Ayello, Elizabeth A.; Coutts, Patricia M.; Garde, Dianne E. 

1 comment:

Øystein said...

Great post! Thanks for mentioning my video :) Check out some stoma pictures I've taken here (screen right).